REQUEST FOR OUTREACH DATE CHANGES
TODAY’S DATE: ___________________________________________
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STUDENT A
NAME: ________________________________________ CLASS
GROUP:___________________________________________ STUDENT A
SIGNATURE: __________________________________ |
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STUDENT B
NAME: _______________________________________ CLASS
GROUP:__________________________________________ STUDENT B
SIGNATURE: _________________________________ |
EVENT CHANGES:________________________________________
STUDENT A TO TAKE:____________________________
STUDENT B TO TAKE:____________________________
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FOR OFFICE USE ONLY
CLINIC COORDINATOR’S
DECISION_________________________
ATTENDANCE CHANGE COMPLETE: ? DATE______ INITIAL: ____
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